Peroral Esophageal Myotomy Research Articles

Tu1172 Correlation Between High-Resolution Manometry Metrics and Symptoms, Symptomatic Outcomes of Peroral Esophageal Myotomy in Achalasia

Tu1172 Correlation Between High-Resolution Manometry Metrics and Symptoms, Symptomatic Outcomes of Peroral Esophageal Myotomy in Achalasia

The potential and perspective of peroral endoscopic esophageal myotomy for achalasia.

The therapeutic spectrum of this disorder consists of medical therapy, endoscopic balloon dilatation, endoscopic Botox injection, open or laparoscopic cardia myotomy, and most recently transesophageal endoscopic myotomy (POEM peroral endoscopic myotomy). The most important requirement is a well-experienced team in interventional flexible endoscopy. The endoscopist as well as the assisting staff should have experience in advanced therapeutic endoscopic techniques and hemostasis to handle all necessary endoscopic instruments such as injection needles, needle knife, triangle knife, coagulation graspers, and endoscopic clip handling and closures. In addition, advanced surgical and especially laparoscopic skills and experience as well as surgical knowledge about esophageal disease must be available in case of conversion and/or consultation. Prior to this procedure, the patient undergoes a detailed diagnostic work-up to confirm the diagnosis of achalasia. The procedures are performed in general anesthesia. The patient is brought in a supine position, and the abdomen is free for inspection and palpation during the procedure. The myotomy can be performed in different locations around the esophageal circumference. In Europe, several centers with large experience in esophageal disease, laparoscopy, and especially advanced interventional endoscopy have started to introduce this POEM-technique in their clinical practice. Initial success and low complication rates are quite promising and show a great future perspective for this technique. In the USA, POEM is a procedure with a substantial increase in numbers performed in the past years with a low complication rate. The largest series are performed in Asia with a great clinical success. The perspective of POEM may be the lesser access trauma. Its potential can be also realized in Redo cases, where experienced centers have initial experience with POEM after POEM and POEM after LHMD.

Peroral esophageal myotomy versus laparoscopic Heller's myotomy for achalasia: a meta-analysis.

This meta-analysis aims to add convincing evidence on the application of peroral esophageal myotomy (POEM), compared with laparoscopic Heller's myotomy (LHM), for the treatment of achalasia. The electronic databases of PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Embase (up to December 2013) were systematically searched. EndNote(®) X6 citation software (Thomson Reuters, New York, NY) was used for literature management. A modification of the Newcastle-Ottawa Scale was applied for quality assessment. The data were analyzed using Review Manager version 5.1 software (The Cochrane Collaboration, Oxford, United Kingdom), and sensitivity analysis was performed by sequentially omitting each study. Overall, four studies compared the outcomes between POEM and LHM. All studies were conducted in the United States and published in 2013. POEM was associated with comparable complications (odds ratio [OR]=1.17, 95% confidence interval [CI] 0.53-2.56, P=.70), gastroesophageal reflux (OR=1.00, 95% CI 0.38-2.61, P=1.00), and symptomatic recurrence by Eckardt score (OR=0.24, 95% CI 0.04-1.55, P=.13). Other outcomes including pain score, operating time, and hospital stay were assessed with no significant difference between POEM and LHM. POEM achieves equivalent short-term outcomes compared with LHM for achalasia. This novel procedure is a promising treatment for achalasia.

Effect of peroral esophageal myotomy for achalasia treatment: A Chinese study.

To assess the safety and feasibility of peroral esophageal myotomy (POEM) in patients with achalasia. From January 2012 to March 2014, 50 patients (28 men, 22 women; mean age: 42.8 years, range: 14-70 years) underwent POEM. Pre- and postoperative symptoms were quantified using the Eckardt scoring system. Barium swallow and esophagogastroscopy were performed before and after POEM, respectively. Esophageal motility was evaluated in all patients, both preoperatively and one month after POEM treatment, using a high-resolution manometry system. Manometry data, Eckardt scores, lower esophageal sphincter pressure and barium swallow results were used to evaluate the effect of the procedure. POEM was successfully completed for all patients. The mean procedure time was 55.4 ± 17.3 min and the mean total length of myotomy of the circular esophagus was 10.5 ± 2.6 cm. No specific complications occurred, with the exception of two patients that developed asymptomatic pneumomediastinum and subcutaneous emphysema. Clinical improvement in symptoms was achieved in all patients. Approximately 77.5% of patients experienced weight gain 6 mo after POEM, with an average of 4.78 kg (range: 2-15 kg). The lower esophageal sphincter resting pressure, four second integrated relaxation pressure and Eckardt scores were all significantly reduced after POEM (Ps < 0.05). A small segment of proximal esophageal peristalsis appeared postoperatively in two patients, but without normal esophageal peristalsis. The average diameter of the esophageal lumen decreased significantly from 4.39 to 3.09 cm (P < 0.01). POEM can relieve achalasia symptoms, improve gastroesophageal junction relaxation and restore esophageal body motility function, but not normal esophageal peristalsis.

Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes.

The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms. Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: (1) at baseline after induction of anesthesia, and (2) after operation completion. Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7 ± 3.1 vs. 5.1 ± 3.4 mm(2)/mmHg, p < .05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6 mm(2)/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3 mm(2)/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6 mm(2)/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20 % in the middle third (6-9 mm(2)/mmHg) and 36 % in the highest third (>9 mm(2)/mmHg). Patients within an "ideal" final DI range (4.5-8.5 mm(2)/mmHg) had optimal symptomatic outcomes (i.e., Eckardt ≤ 1 and GerdQ ≤ 7) in 88 % of cases, compared with 47 % in those with a final DI above or below that range (p < .05). Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations for achalasia.

An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM.

For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP after each operative step. During LHM and POEM, each patient's myotomy was performed in two stages: first, a myotomy ablating only the EGJ complex was created (EGJ-M), extending from 2 cm proximal to the EGJ, to 3 cm distal to it. Next, the myotomy was lengthened 4 cm further cephalad to create an extended proximal myotomy (EP-M). Measurements were performed in 12 patients undergoing LHM and 19 undergoing POEM. LHM resulted in an overall increase in DI (1.6 ± 1 vs. 6.3 ± 3.4 mm(2)/mmHg, p < 0.001). Creation of an EGJ-M resulted in a small increase (1.6-2.3 mm(2)/mmHg, p < 0.01) and extension to an EP-M resulted in a larger increase (2.3-4.9 mm(2)/mmHg, p < 0.001). This effect was consistent, with 11 (92%) patients experiencing a larger increase after EP-M than after EGJ-M. Fundoplication resulted in a decrease in DI and deinsufflation an increase. POEM resulted in an increase in DI (1.3 ± 1 vs. 9.2 ± 3.9 mm(2)/mmHg, p < 0.001). Both creation of the submucosal tunnel and performing an EGJ-M increased DI, whereas lengthening of the myotomy to an EP-M had no additional effect. POEM resulted in a larger overall increase from baseline than LHM (7.9 ± 3.5 vs. 4.7 ± 3.3 mm(2)/mmHg, p < 0.05). During LHM, an EP-M was necessary to normalize distensibility, whereas during POEM, a myotomy confined to the EGJ complex was sufficient. In this cohort, POEM resulted in a larger overall increase in EGJ distensibility.

Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect

Peroral esophageal myotomy (POEM) differs from laparoscopic Heller myotomy (LHM) in that only the circular muscle layer of the esophagus is divided, the hiatus is not mobilized, and an antireflux procedure is not performed. The effect of these differences on anatomic and functional outcomes is unknown. Patients who underwent LHM or POEM and had both a pre- and postoperative timed barium esophagogram were selected for analysis. Timed barium esophagograms were performed with 200 mL of contrast, with radiographs taken at 1, 2, and 5 minutes. A total o f 17 LHM and 12 POEM patients had undergone pre- and postoperative timed barium esophagograms. Both groups had decreased column heights postoperatively at 1, 2, and 5 minutes (LHM: pre, 15.6, 12.7, 11.3 cm vs post, 3.6, 2.5, 1.8 cm; P < .001 and POEM: pre, 14.7, 11, 9.4 cm vs post, 4.4, 2.5, 1.2 cm; P < .001). There was no difference between procedures in changes from baseline column height. Both operations resulted in decreased esophageal width and less angulation between the esophageal body and esophagogastric junction. POEM and LHM produce a similar short-term anatomic and functional result at the esophagogastric junction. POEM results in a similar narrowing and straightening of the esophagus despite the fact that POEM does not involve hiatal mobilization.

Analysis of a Learning Curve and Predictors of Intraoperative Difficulty for Peroral Esophageal Myotomy (POEM)

BackgroundPeroral esophageal myotomy (POEM) is an endoscopic surgical operation for achalasia. Here, we analyze a single-series POEM learning curve and examine which preoperative patient factors are predictive of operative difficulty. MethodsTwo surgeons performed all POEM procedures conjointly. Nonlinear regression was used to determine the learning curve for procedure time. Preoperative patient characteristics were correlated with outcomes. ResultsThirty-six POEM procedures were performed. Total operative time did not decrease over the course of the series (mean 112 ± 36 min). Time required to complete the procedural steps of submucosal access and myotomy did decrease with experience, both exhibiting a “learning rate” of seven cases. The incidence of inadvertent mucosal perforations and the number of clips required both decreased with experience. Postoperative Eckardt scores at 1-year follow-up decreased over the course of the series. Prior endoscopic treatment, symptom duration, and esophageal width were all independently predictive of longer procedure time. Preoperative symptom duration was also positively associated with inadvertent mucosal perforation and the number of clips required. ConclusionsIn this series, overall procedure time did not decrease with experience and may not be an important marker of procedural skill for POEM. Prior endoscopic treatment, longer symptom duration, and esophageal dilatation may result in increased operative difficulty during POEM.

Continuing Medical Education Questions: August 2013

Questions: Which one of the following statements is true about the epidemiology, pathogenesis, or natural history of achalasia? A. Because there is a higher prevalence of achalasia in men than in women, and particularly in the Caucasian population, these patients with dysphagia should undergo prompt investigation for achalasia, whereas other patient populations should be observed and treated with a more aggressive regimen of PPI therapy. B. The end result of the inflammatory process in achalasia is that of upregulation of cholinergic activity, which subsequently overpowers the inhibitory neurotransmitters nitrous oxide and vasoactive peptide (VIP). This results in an imbalance between excitatory and inhibitory neurons, leading to incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis. C. Because there is a higher prevalence of achalasia in men than in women, and particularly in the Caucasian population, screening for esophageal squamous cell carcinoma should begin at the onset of diagnosis and subsequently every 2 years. D. Owing to poor esophageal emptying and stasis inflammation, patients with achalasia are at an increased risk of not only esophageal squamous cell carcinoma but also adenocarcinoma, although the latter carries a substantially lower risk than that for squamous cell carcinoma. Which one of the following statements is true about confirming a diagnosis of achalasia? A. The endoscopic finding of a strong resistance at the esophagogastric junction (EGJ) when intubating the stomach should lead the physician to a very high suspicion for achalasia; however, motility testing is still needed to confirm a diagnosis of achalasia. B. A barium esophagram demonstrating a dilated esophagus, a “bird-beak” appearance, aperistalsis, and poor emptying of barium has a very high sensitivity and specificity for making a diagnosis of achalasia, and thus, confirmation with esophageal manometry may be redundant. C. A barium esophagram demonstrating a dilated esophagus, aperistalsis, and poor emptying of barium can help confirm a diagnosis of achalasia in cases where esophageal manometry may have indeterminate findings. D. In patients with high clinical suspicion of achalasia, the absence of a mechanical obstruction on endoscopy or esophagram is sufficient evidence to make a diagnosis of achalasia with > 95% accuracy. In the following clinical scenarios, which treatment recommendation is the appropriate therapy for patients with achalasia? A. For all patients with a new diagnosis of achalasia, oral pharmacologic therapies (e.g., calcium channel blockers or long-acting nitrates) should be the initial therapy because they are effective and the least invasive options. B. For medically fit patients, either graded pneumatic dilation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy because both methods provide good relief of symptoms with comparable success rates. C. In the patients who are undergoing surgical myotomy, preoperative Botulinum toxin therapy should be given to improve surgical outcomes. D. For patients who develop “end-stage” achalasia characterized by megaesophagus or sigmoid esophagus and significant esophageal dilation and tortuosity, per-oral esophageal myotomy (POEM) should be recommended because it has been shown to be a more effective treatment option than surgical esophagectomy in a randomized prospective trial.

Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia

Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications. We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device. An anterior esophageal 2cm mucosectomy is created 7-10cm proximal to the gastroesophageal junction after a submucosal wheal is raised. A submucosal tunnel is created and extended to 2cm on the gastric cardia. A selective circular myotomy is performed. The mucosectomy is closed using endoscopic clips. An inadvertent full-thickness esophagotomy was created while performing the mucosotomy on an inadequate submucosal wheal. We were able to resume the POEM technique at the initial esophagotomy site. There was a discussion to convert to laparoscopy. However, as we succeeded in creating the tunnel, we continued with the POEM technique. After the selective myotomy was completed, we used an endoluminal suturing device (Overstitch, Apollo Endosurgery, Austin TX) to close the full-thickness esophagotomy in two layers (muscular, mucosal). A covered stent was not an option because the esophagus was dilated, which precluded adequate apposition. The patient had an uneventful postoperative course. At 9-month follow-up, had excellent palliation of dysphagia without reflux. This case demonstrates the importance of identifying extramucosal intrathoracic anatomy, thus emphasizing the need for an experienced surgeon to perform these procedures, or at a minimum to be highly involved. Raising an adequate wheal is crucial before mucosectomy. Inadequacy of the wheal may reflect local esophageal fibrosis. If this fails at multiple locations in the esophagus, it may be prudent to convert to laparoscopy. This case also demonstrates the need for advanced flexible endoscopic therapeutic tools and a multidisciplinary approach to manage potential complications.

452 Analysis of a Single-Series Learning Curve for PerOral Esophageal Myotomy (POEM)

Background: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. The operator learning curve for POEM and patient factors associated with operative difficulty are not known. Methods: A single-institution prospective POEM outcomes database was analyzed. All POEM procedures were performed conjointly by the same two surgeons. Associations between preoperative patient variables (series case number, gender, age, BMI, ASA class, prior treatment with dilation or Botox, symptom duration, manometric pressures, achalasia subtype) and operative outcomes (procedure time, tunnel length, myotomy length, number of clips used for closure, EBL, mucosal perforation, need to decompress pneumoperitoneum) were tested using bivariate linear correlation. To assess for changes in efficiency over the course of the series, the total procedure time and the time required for each individual procedural step (submucosal access, tunnel creation, myotomy, and mucosal closure) were tested for best fit to linear, logarithmic, and exponential regression curves using case number as the dependent variable. A subgroup analysis of treatment-naive patients was secondarily performed. Results: 30 patients underwent POEM, of which 26 were treatment-naive. Preoperative symptom duration was positively associated with increased operative time (r^2=.55, p,.01). Prior achalasia treatment and EGJ resting pressure were both positively associated with operative time at a trend level (p=.08 for both). Case number correlated negatively with the number of clips required for closure (r^2=-.51, p ,.01), whereas duration of symptoms was positively correlated with clip number (r^2=.40, p,.05). Case number correlated negatively, whereas duration of symptoms correlated positively, with occurrence of a mucosal perforation, both at a trend level (p=.06 and .07). Myotomy length proximal to the EGJ increased over the course of the series (r^2=.44, p=.02), whereas there was no change in myotomy length distal to the EGJ. Total procedure time and time to perform tunnel creation, myotomy and mucosal closure did not change over the course of the series. Submucosal access time decreased over the course of the series (r^2=.22, p,.01) with best fit to a logarithmic curve. In treatment-naive patients only, mucosal closure time decreased over the series (r^2=.17, p=.03) with best fit to an exponential curve. Conclusions: In this POEM series, the time needed to access the submucosa and the number of clips required to close the mucosotomy both decreased with experience. Myotomy length proximal to the EGJ increased with experience. Total procedure time did not change over the course of the series, and may not be an important marker of procedural skill for POEM. Longer symptom duration and prior endoscopic treatment may result in increased operative difficulty.